Posterior Reversible Encephalopathy Syndrome in Children: Its High Prevalence and More Extensive Imaging Findings

Ishikura, Kenji; Ikeda, Masahiro; Hamasaki, Yuko; Hataya, Hiroshi; Shishido, Seiichirou; Asanuma, Hiroshi; Nishimura, Gen; Hiramoto, Ryugo; Honda, Masashi

doi:10.1053/j.ajkd.2006.04.076

Cited by 99 publications

(104 citation statements)

References 22 publications

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“…A possible correlation between low albumin levels and PRES is supported by Ishikura et al, 23 who reported 7 pediatric patients who developed PRES during nephrotic syndrome and low levels of serum albumin. In these patients, PRES rapidly abated after substitution of albumin, despite further treatment with cytotoxic substances.…”

Section: Kssupporting

confidence: 51%

Type of Edema in Posterior Reversible Encephalopathy Syndrome Depends on Serum Albumin Levels: An MR Imaging Study in 28 Patients

Pirker¹,

Kramer²,

Voller³

et al. 2011

AJNR Am J Neuroradiol

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SUMMARY: PRES is a clinicoradiologic entity, combining seizures, blindness, and coma with MR imaging findings of predominantly vasogenic and occasional cytotoxic edema. In this clinical report, we determined the type of edema by using DWI and FLAIR sequences on MR imaging as well as ADC maps in 28 patients with PRES. The neuradiologic findings were correlated with levels of serum albumin, which is a main contributor to colloid osmotic pressure and vascular integrity. The presence of vasogenic edema was significantly associated with decreased serum albumin levels, which may be a particular risk factor for the development of PRES.ABBREVIATIONS: ADC ϭ apparent diffusion coefficient; ANOVA ϭ analysis of variance; CI ϭ confidence interval; COP ϭ colloid osmotic pressure; DWI ϭ diffusion-weighted imaging; FLAIR ϭ fluid-attenuated inversion recovery; IL ϭ Interleukin; KS ϭ Kolmogorov-Smirnov; MWU ϭ Mann Whitney U; NO ϭ nitric oxide; PRES ϭ posterior reversible encephalopathy syndrome; ROS ϭ reactive oxygen species P RES is a clinicoradiologic entity with acute onset of seizures, blindness, alterations of consciousness, and headache. MR imaging is of great importance in the diagnosis of this clinically inhomogeneous syndrome, which typically shows bilateral signal-intensity alterations in cortical and subcortical regions of the posterior circulation, indicating vasogenic edema.1 A low proportion of patients show cytotoxic edema or lesions outside the posterior circulation.2 An association between the etiology of PRES and MR imaging findings has been negated in a recent investigation.3 Additionally, it remains unclear why patients develop either vasogenic or cytotoxic edema in PRES. Cytotoxic and vasogenic edema in PRES can be differentiated by using DWI and FLAIR sequences. 4 It has been postulated that PRES is caused by endothelial damage and dysfunctional cerebral autoregulation due to excessive hypertension, leading to hyperperfusion and subsequent vasogenic edema in susceptible vessels. 5,6 Other risk factors are pre-eclampsia, sepsis, cytotoxic and immunosuppressant drugs, and nephrotic syndrome.7 These conditions all involve high oxidative stress and a systemic proinflammatory process, 8 hinting at additional mechanisms involved in PRES pathogenesis, such as vasoactive substances, vasospasm, and microinfarctions. 9 As seen in nephrotic syndrome, most diseases associated with PRES exhibit significantly reduced serum albumin levels.10 Serum albumin accounts for 75% of plasma protein and, therefore, is a main contributor to COP, reducing perfusion pressure, which results in retention of fluid in the vessel. 11Vasogenic edema can be aggravated by a marked decrease in COP. 12 Albumin protects vascular endothelial cells from oxidative stress and damage, 13 acting as an important antioxidant that preserves vascular integrity.This clinical report describes 28 patients with PRES and focuses on the type of edema in correlation with serum albumin. We show that vasogenic edema in PRES occurs significantly more often in patien...

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Section: Kssupporting

confidence: 51%

Type of Edema in Posterior Reversible Encephalopathy Syndrome Depends on Serum Albumin Levels: An MR Imaging Study in 28 Patients

Pirker¹,

Kramer²,

Voller³

et al. 2011

AJNR Am J Neuroradiol

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“…More extensive brain involvement was demonstrated by more sensitive imaging techniques (DWI, FLAIR, and proton MR spectroscopy), even in patients with normal findings in CT-B and contrast-enhanced MRI studies [7,8,22,25,26]. Moreover, pediatric series reported diffuse brain involvement, including the brainstem and the cerebellum, as well as frequently detected extensive gray matter findings [3,27]. More current reports are strongly suggesting the use of DWI and apparent diffusion coefficient (ADC) maps for more accurate diagnosis and better prediction of PRES outcomes [28,29].…”

Section: Discussionmentioning

confidence: 93%

Posterior reversible encephalopathy syndrome in the pediatric renal population

et al. 2007

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Posterior reversible leukoencephalopathy syndrome (PRES) clinically presents with seizures, severe headaches, and mental and visual changes. Our goal was to describe the clinical features, triggering factors, neuro-imaging findings, and electroencephalogram (EEG) findings in a pediatric cohort with renal disease. We retrospectively analyzed the records of 18 children with the diagnosis of PRES between January 2001 and June 2006 at the University of Miami/Holtz Children's Hospital, USA. There were 22 PRES episodes. The most common clinical presentation was generalized tonic-clonic seizures in 59% (13/22). The most common identified trigger of PRES was hypertensive crisis in 59% (13/22). Almost half of the children had no evidence of on-going uncontrolled hypertension; 44% (8/18) had normal funduscopic examination findings, and 50% (9/18) had no or mild left ventricular hypertrophy. Two of the 18 patients had recurrent PRES episodes, three episodes each. Diffuse slowing was the most common finding on the EEGs. Atypical magnetic resonance imaging (MRI) findings were more prevalent in the imaged cases (62% vs 25%, P < 0.05). All the computerized tomography (CT) scans were normal, despite the positive MRI findings in four cases when both types of imaging was used. All the episodes had total clinical resolution. In conclusion, despite the diverse initial trigger, acute hypertension seems to be the common pathogenic pathway for pediatric PRES. MRI seems superior to CT, with better sensitivity due to its high resolution and diffusion-weighted imaging. The lesions do not necessarily have to be in the posterior white matter and may not be totally reversible.

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“…Classically, PRES lesions have been described predominantly in the parieto-occipital lobes, but may also be found in the frontal lobe, basal ganglia, thalamus, brainstem and subcortical white matter [31]. A recent study showed a high percentage of grey matter involvement [32]. Usually, lesions are due to vasogenic oedema with an increase in ADC [33].…”

Section: Discussionmentioning

confidence: 99%

Patterns in early diffusion-weighted MRI in children with haemolytic uraemic syndrome and CNS involvement

et al. 2011

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Posterior Reversible Encephalopathy Syndrome in Children: Its High Prevalence and More Extensive Imaging Findings

Cited by 99 publications

References 22 publications

Type of Edema in Posterior Reversible Encephalopathy Syndrome Depends on Serum Albumin Levels: An MR Imaging Study in 28 Patients

Type of Edema in Posterior Reversible Encephalopathy Syndrome Depends on Serum Albumin Levels: An MR Imaging Study in 28 Patients

Posterior reversible encephalopathy syndrome in the pediatric renal population

Patterns in early diffusion-weighted MRI in children with haemolytic uraemic syndrome and CNS involvement

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